Transcript
Authorization to Release Medical Records Records to be released from
Interventional Pain Care, LLC 5501 W. Bethel Ave. Muncie, IN 47304
I hereby request and authorize the above provider to furnish records for the purpose of ____________________________________________________ or at my request. Records to be sent to: Provide complete name, address, and zip code
_________________________________________ _________________________________________ _________________________________________
Patient Information Patient Name _______________________________ Address _______________________________ City, State, Zip _______________________________
Phone DOB SS#
________________ _________________ _________________
Information that may be released: ___ All records ___ Office Visit Notes ___ Prescription ___ Labs ___ History & Physical ___ Consultation report(s) ___ Therapy notes ___ Discharge Summaries ___ Image reports (MRI, x-ray, etc.) ___ Operative Reports ___ Other __________________________________ ___ I understand that this release also pertains to records regarding drug and alcohol treatment, mental health records, and communicable disease records, including HIV and AIDS. Limitations: Do not release information in my record regarding ______________________________. Release my records only for dates of _________________________ through ____________________. I understand that (1) I may revoke this authorization at any time in writing, except to the extent that authorization has been taken based upon it; (2) that the recipient of these records may further disclose the information because of this authorization and it may then no longer be protected by Federal Privacy Regulations; (3) I am entitled to ask for a copy of this document; (4) I may refused to sign this authorization and my refusal to sign will not affect my ability to obtain treatment. There may be a discharge for the release of these records pursuant to Indiana Code 16-39-9-3 and CPR 164.524 (HIPAA). Signature of patient or patient representative __________________________________________________ Description of representative’s authority to act for patient _______________________________________ Date signed __________________ Expiration: 60 days or earlier date of _____________________
Authorizations for health records as defined by Indiana Statute may not be effective for longer than 60 days.
5501 W. Bethel Ave. Muncie, IN 47304 With locations in Muncie, Hartford City, Fishers, Upland, and Shelbyville phone: 765-741-2957 toll free: 877-472-5548 fax: 765-747-3310
